Predictors of Mortality and Hospitalization for Cardiac Causes in Patients with Heart Failure and Nonischemic Heart Disease: A Subanalysis of the ALPHA Study

Background: Several studies have searched for predictors of clinical outcome in patients with heart failure (HF). However, since they were collected in clinical trials, most data were subject to selection biases and do not specifically apply to patients with nonischemic heart disease. This study examined the impact of several variables on combined all-cause mortality and hospitalization for cardiac causes, in consecutive ambulatory patients with HF included in the ALPHA registry.
Methods and Results: This analysis included 446 patients with HF and nonischemic heart disease, in New York Heart Association functional class II or III, and a left ventricular (LV) ejection fraction below 40%. In 126 patients (73%) the disease was idiopathic dilated cardiomyopathy, in 72 (16%) hypertensive, in nine (2%) valvular, and in 39 (9%) of other etiologies. The median age was 61 years (range 51–69 years) and 349 (78%) patients were men. Over a median follow-up of 31 months (range 23–40), 82 patients (18%) died or were hospitalized for cardiac causes. In a proportional hazard (Cox) regression model, maximal oxygen consumption (HR 0.9, P = 0.001), LV end-diastolic diameter (HR 1.07, P < 0.001), resting systolic blood pressure (HR 0.97, P < 0.005), and hemoglobin (HR 0.86, P < 0.05) were independent predictors of the combined study endpoint.
Conclusions: In an unselected population of patients with HF and nonischemic heart disease, a reduced exercise capacity, large LV end-diastolic diameter, low systolic blood pressure, and hemoglobin were correlated with long-term all-cause mortality or hospitalization for cardiac causes. These observations may help stratifying and tailoring the treatment of patients with HF and nonischemic heart disease.     

Passage of Gliadin into Human Breast Milk

ABSTRACT. Samples of breast milk were taken from 53 women following the ingestion of 20 g of gluten. The samples were analysed for the presence of gliadin by a double-antibody sandwich enzyme immunoassay. Gliadin (5–95 ng/ml) was detected in 54/80 samples collected at various stages of lactation. Maximum levels in milk were found 2–4 hours after ingestion; gliadin could not be detected in serum. The transfer of gliadin from mother to infant might be critical for the development of an appropriate specific immune response to gliadin later in life.     

Role of Implantable Cardioverter Defibrillators in Dilated Cardiomyopathy

ICDs in Dilated Cardiomyopathy. Idiopathic dilated cardiomyopathy (DCM) accounts for about 10,000 deaths per year in western countries. Of these deaths, 8% to 51% occur suddenly, with more than half of the events due to a ventricular arrhythmia. Improvement in diagnostic techniques and therapeutic strategies, together with changes in secular trends, have likely contributed to the reported trend toward improved survival in recent years. Identification of DCM patients at higher risk of sudden death is difficult. Poor left ventricular function is the strongest predictor of all‐cause death, whereas a history of sustained unstable ventricular arrhythmia or cardiac arrest identifies patients at high risk of sudden death. Recent data suggest that a history of syncope, regardless of inducibility at programmed electrical stimulation, may be a risk factor of sudden death. Despite the absence of controlled studies, use of implantable cardioverter defibrillator therapy for primary prevention can be considered in patients with unexplained syncope as well as subgroups of DCM patients awaiting transplantation. In patients who survive a cardiac arrest or an unstable ventricular tachycardia, use of implantable cardioverter defibrillator therapy is associated with improved survival during follow‐up and should be considered as a first‐line therapy.     

Dermoscopic Features of Difficult Melanoma

BACKGROUND: The dermoscopic diagnosis of cutaneous melanoma (CM) may be difficult because some CM lack specific dermoscopic features for melanoma diagnosis. OBJECTIVE: To evaluate whether a diagnosis of CM could be achieved using the classic dermoscopic melanoma-specific criteria, we conducted a retrospective multicenter study of 508 CM samples. METHODS: All the dermoscopic images were analyzed to identify the dermoscopic criteria found in dermoscopically difficult melanomas (DDM) and to examine the possible relation of dermoscopic diagnosis with respect to the difficulty of the dermoscopic diagnosis and the melanoma thickness. RESULTS: A significant percentage of melanomas, 89 of 508 (17.5%), were DDM. The criteria leading to a significant increased risk of DDM were presence of streaks [odds ratio (OR), 2.26; 95% confidence interval (CI), 1.15-4.47), absence or presence of regular pigmentation (OR, 3.41; 95% CI, 1.70-6.85), absence of a blue-whitish veil (OR, 4.04; 95% CI, 2.33-6.99), absence of regression structures (OR, 4.31; 95% CI, 2.42-7.66), and the presence of hypopigmentation (OR, 2.61; 95% CI, 1.49-4.58). CONCLUSION: A significant number of melanomas defy even dermoscopic diagnosis. Only a meticulous comparative and interactive process based on an assessment of all the individual's other nevi ("ugly ducking" sign) and a knowledge about recent changes can lead to the recognition of DDM.